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MND Update: Adult Sleep Studies Performed in the Home

Horizon Blue Cross Blue Shield of New Jersey is implementing a change in our processes and procedures related to medical necessity determination (MND) reviews of sleep study services performed in adult patients’ homes.

Beginning May 1, 2015, Horizon BCBSNJ will no longer conduct pre-service medical necessity determinations for sleep study services for adult patients (18 years of age and older) that are to be performed in the patient’s home.

As part of our efforts to help ensure that claims for other sleep study services are properly considered for reimbursement, we continue to conduct MND reviews of sleep study procedures prior to the services being rendered for adult members that are to be performed in a sleep testing facility, attended by a sleep technologist.

Ordering physicians should follow the steps below to initiate a pre-service MND for sleep study services to be performed in a sleep testing facility, attended by a sleep technologist:

  1. Visit HorizonBlue.com/Providers.
  2. Mouse over Forms and click Forms by Type.
  3. Click Inquiry/Request and then click Fax Pre‐Determination-Diagnosis of Obstructive Sleep Apnea.
  4. Fax the completed form to 1‐888‐608‐1015.

Failure to obtain an approved MND prior to rendering sleep study services to an adult patient in a sleep testing facility may result in a delay in claim payment, while information to support the medical necessity of the sleep study services provided are requested from the ordering physician and reviewed.

If a post‐service MND review determines that the services performed were not medically necessary or appropriate based on our medical policy, Diagnosis of Obstructive Sleep Apnea, claims will be denied. Participating providers may not bill members for claims denied based on utilization management determinations and/or non‐compliance with our utilization management requirements.

The medical policy, Diagnosis of Obstructive Sleep Apnea, is available for review in our online Medical Policy Manual.

If you have questions, please call Physician Services at 1-800-624-1110 or the Centralized Service Center at 1-888-666-2535, Monday through Friday between 8 a.m. and 5 p.m., Eastern Time.

Published on: April 21, 2015, 14:00 p.m. ET
Last updated on: November 24, 2020, 23:33 p.m. ET