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Pediatric Sleep Studies

Horizon Blue Cross Blue Shield of New Jersey has changed processes and procedures related to medical necessity determination (MND) reviews of pediatric sleep study services.

As of February 2015, Horizon BCBSNJ does not conduct pre-service MNDs for sleep study services to be performed for patients 17 years of age and younger.

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.

Pre-service MNDs for Adult Patients (18 years of age and older)

To help ensure that claims for sleep study services are properly considered for reimbursement, Horizon BCBSNJ continues to conduct MND reviews of sleep study procedures prior to the services being rendered for adult members (18 years of age and older).

To initiate a pre-service MND for sleep study services ordering physicians should fax a completed copy of our Pre‐Determination for Diagnosis of Obstructive Sleep Apnea form to 1‐888‐608‐1015.

Failure to obtain an approved MND prior to rendering sleep study services to an adult patient may 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.

Published on: March 19, 2015, 08:00 a.m. ET
Last updated on: November 24, 2020, 23:30 p.m. ET