Sleep studies and therapy prior authorization and utilization management program

Effective January 1, 2010, FCHP will be partnering with Sleep Management Solutions (SMS) to provide sleep diagnostic and therapy management services for selected FCHP product lines as listed below.  This partnership with SMS in conjunction with CareCore National (CCN) is designed to improve the overall quality of sleep services and ensure appropriate use of such services. 

This program will provide home sleep testing for appropriate patients as identified by the new sleep criteria.  Utilizing guidelines consistent with the American Academy of Sleep Medicine (AASM) and CMS, CCN will review your request for a sleep study and make recommendations for those studies that can be performed in the member’s home. If the member is not appropriate for a home sleep study, the member will be directed to a FCHP-contracted sleep facility.  The sleep program provided by SMS and CCN uses evidence-based criteria to ensure all requests meet quality standards.  You can review SMS’s medical necessity criteria at www.sleepmanagementsolutions.com or at www.carecorenational.com.

Products included in the prior authorization and utilization management program for sleep studies and therapy are:

FCHP Direct Care
FCHP Select Care
Commonwealth Care
Major Medical
Fallon Senior Plan HMO

Companion Care, FCHP MassHealth, Fallon Preferred Care, Fallon Senior Plan PPO, Summit ElderCare, and NaviCare HMO are not included in this program.

Prior authorization

Effective for dates of service beginning January 2, 2010, FCHP will require you to request authorization from CCN prior to an FCHP member receiving a sleep study (polysomnography) and/or sleep therapy (CPAP, bi-level, bi-level ST, and all PAP supplies) services.  Failure to notify CCN in advance of delivering a sleep study will result in administrative service and claims payment denials.   

  • Sleep diagnostics (94660, 94799, 95805, 95806, 95808, 95810, 95811)
  • Therapy ( E0470, E0471, E0561, E0562, E0601)
  • Supplies (A4604, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046)

As the referring primary care physician, you are responsible for obtaining the required authorization number prior to performance of requested sleep studies.  Upon review of the request, CCN will make medical necessity and site of service determinations within two business days for standard requests after submission of all requested clinical documentation (three hours for urgent requests). You will receive the authorization or denial by fax. Approvals will contain a CCN authorization number and a CPT code specific to the requested procedure.

If the requested sleep study can be performed in the FCHP member’s home, SMS will provide the HST distribution, patient education, study interpretation, recommendation to the PCP who ordered the test, and the initiation of APAP therapy when appropriate.  All patients receiving PAP therapy will be enrolled in the SMS iComply Compliance Program. 

If the sleep study is to be performed at a sleep lab, SMS recommends sleep lab facilities obtain the authorization number from the referring physician at the time the procedure is scheduled. If you do not have an authorization number, please call CCN Monday through Friday, 8 a.m. to 5:30 p.m. Eastern time, at 1-800-630-3493 or via fax at 1-866-999-3510, by utilizing the CCN secure web portal at www.carecorenational.com.

NOTE: Accurate claims payment requires matching of the billed CPT codes to the authorized CPT codes. 

Our aim is to make the new prior authorization program as easy as possible. We offer three methods to obtain prior authorization from CCN; by internet (at www.carecorenational.com), by phone and by fax.  We have included a reference guide which provides useful information to assist you with the prior authorization process.  Please note that the authorization number must be submitted with the claim in order to be paid.  Claims for services that require prior authorization which are lacking an authorization number will be denied, effective 1/2/2010.

Questions about the sleep study and therapy program

If you have any questions regarding this new program or about Sleep Management Solutions, please contact Sleep Management Solutions Customer Service Department at 1-888-693-3211, option # 3, or the FCHP Provider Relations Department Monday through Friday, 8:30 a.m. to 5:00 p.m. at 1-866-ASK-FCHP, prompt 4.