Sleep Studies

Resources

Setting	Details
Home	Blue Care Network requires plan notification to facilitate claims payment or prior authorization for sleep studies as follows. 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.
Home	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.
	For Blue Cross commercial members: All fully insured groups and individual members Most self-funded groups Includes UAW Retiree Medical Benefits Trust non-Medicare members For exceptions, see the Carelon exclusion list for Blue Cross Blue Shield of Michigan Commercial The requirements outlined above don't apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

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.

How to submit prior authorization requests

To learn how to submit requests, see our Getting Started page.

Submit requests before providing services.

Utilization management criteria

To view, visit our Utilization management criteria page.