Sleep Studies

Blue Care Network requires plan notification to facilitate claims payment or prior authorization for sleep studies as follows.

Setting Details
Home For BCN commercial members:
  • In the East and Southeast regions, submit plan notification to BCN through the e-referral system to facilitate claims payment (clinical review isn’t needed).
  • In the Mid, West and Upper Peninsula regions, plan notification isn’t required. Providers don’t need to submit anything in the e-referral system.
  • In all regions, prior authorization is required when the provider is out-of-network for the member’s plan.
    • Note: Providers who are part of a medical care group must follow the requirements that apply to the region in which the medical care group’s headquarters is located.
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.
In lab For BCN commercial members:
  • For adult members
    • For dates of service on or after Sept. 1, 2023: Submit requests to Carelon Medical Benefits Management.
    • For dates of service before Sept. 1, 2023: Submit requests to BCN through the e-referral system.
  • For pediatric members (17 years of age or younger):
    • In the East and Southeast regions, submit plan notification to BCN through the e-referral system to facilitate claims payment (clinical review isn’t needed).
    • In the Mid, West and Upper Peninsula regions, plan notification isn’t required. Providers don’t need to submit anything in the e-referral system.
    • In all regions, prior authorization is required when the provider is out-of-network for the member’s plan.
Note: Providers who are part of a medical care group must follow the requirements that apply to the region in which the medical care group’s headquarters is located
For BCN Advantage members:
  • For dates of service on or after Oct. 9, 2023: Prior authorization is required for BCN Advantage members only when the provider is out of network for the member’s plan. Submit requests to BCN through the e-referral system.
  • For dates of service before Oct. 9, 2023: Prior authorization is required for all BCN Advantage members. Submit requests to BCN through the e-referral system.

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.

Utilization management criteria

Resources for services managed by BCN

Resources for services managed by Carelon

Additional resources

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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.