Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will implement a new Sleep Management Program. The new program will consider the medical necessity of studies and the clinical appropriateness of a facility- or home-based test. Prior authorization will also be required for coverage of any subsequent treatment (therapy), both initial and ongoing.

Providers must submit a prior authorization request and specified clinical information for home and facility-based sleep testing services, which will result in the approval or denial of coverage for the following non-emergency, outpatient and / or facility and home-based sleep testing and therapy services:

• Home sleep test (HST)
  
• In-lab sleep study (PSG)
• Certain oral devices 
• Neurostimulators

Both ordering physicians (those referring the member for sleep testing and therapy) and servicing providers may submit requests for sleep testing and therapy on behalf of Blue Cross NC members. 

The program will be administered by Carelon Medical Benefits Management.

Prior Plan Approval: Commercial members will require prior authorization through the Carelon Provider Portal or by phone.

The Prior Approval list is updated on a quarterly basis, within the first 10 days of January, April, July, and October. If there is no update within this time period, the list will remain unchanged until the following quarter. Unlisted and miscellaneous health services codes should only be used if a specific code has not been established by the American Medical Association.

To request prior approval for sleep management:

• Visit the Carelon Provider Portal in Blue e (under Health Management - Sleep Management)
  
• Or call Carelon Medical Benefits Management at 866-455-8414 (Monday through Friday, 8 AM to 6 PM, ET)