Blue Care Network requires plan notification to facilitate claims payment or prior authorization for sleep studies as follows.
For BCN commercial members:
|For BCN Advantage members: Prior authorization is required only when the provider is out of network for the member’s plan. Submit requests to BCN through the e-referral system.
For BCN commercial members:
For BCN Advantage members:
Important: Only providers who have signed a specific sleep testing agreement may provide sleep management services to BCN members. Home sleep study providers can be identified using BCN’s online provider search at on the Find Care page on bcbsm.com. Search for “home sleep testing”. For more specific instructions, refer to the document titled Finding home sleep study providers.
For information about cardiology services for Blue Cross Blue Shield of Michigan commercial and Medicare Plus BlueSM members, see the Blue Cross Sleep Studies page.
How to submit prior authorization requests
To learn how to submit requests, see our Getting Started page.
Submit requests before providing services.
Positive airway pressure devices for the treatment of obstructive sleep apnea
BCN provides coverage for PAP devices for members who meet medical necessity criteria. The guidelines for initial coverage are found in our Sleep Disorders — Diagnosis and Medical Management medical policy. (To access this policy, open the Medical Policy Router Search page on bcbsm.com and enter the name of the policy of the policy in the Policy/Topic Keyword field.)
Members who use PAP devices must show they’re complying with their treatment recommendations to use the device for longer than 90 days. This applies to requests for clinical review for BCN commercial and BCN Advantage members. For members who meet the initial criteria for these devices, Northwood, Inc., BCN’s durable medical equipment benefit manager, will authorize use of the devices for a three-month period.
Resources for services managed by BCN
- Blue Cross and BCN medical policies — Open our Medical Policy Router Search page on bcbsm.com. Enter a procedure code in the Policy/Topic Keyword field.
- Finding home sleep study providers (PDF)
Resources for services managed by Carelon
- Procedures that require prior authorization by Carelon: Cardiology, radiation oncology, radiology (high technology) and sleep studies (in lab) (PDF)
- Frequently asked questions about Carelon: For cardiology, radiology (high technology) and sleep studies (in lab) (PDF) — Answers to questions about prior authorization requirements for cardiology, high-tech radiology and in-lab sleep studies
- Carelon's Clinical guidelines and pathways*
- Sleep studies: For prior authorization determinations (PDF) — Includes information about utilization management programs
*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.
Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.