Sleep studies and therapy prior authorization and utilization management program

Fallon Health partners with CareCentrix to provide sleep diagnostic and therapy management services for selected Fallon product lines as listed below. This partnership with CareCentrix is designed to improve the overall quality of sleep services and ensure appropriate use of such services. 

Fallon Health products

All Fallon products are included in the program for sleep studies and therapy except: Fallon Medicare Plus Medicare Supplement, NaviCare^® and Summit ElderCare^®.

Evaluation of requests

Using evidence-based and industry-accepted guidelines, CareCentrix 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 an CareCentrix-contracted sleep facility, as CareCentrix will be administering our sleep diagnostic and therapy networks.

The sleep program provided by CareCentrix was developed to ensure all requests meet quality standards.

Review the Fallon-specific medical necessity criteria:

• Diagnosis of Sleep Disordered Breathing in Adults and Children
• Criteria for Determining the Medical Necessity for the Treatment of Sleep Disordered Breathing in Adults and Children

Prior authorization

The following services require prior authorization:

• Sleep diagnostics 95805, 95806, 95810, 95811, 95872, 95873, G0399, and G0398
• Sleep therapy E0470, E0471, E0561, E0562, E0601
• Related supplies A4604, A7027, A7028, A7029, A7030, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046

Fallon Health requires that the ordering physician request authorization from CareCentrix prior to a Fallon member receiving sleep study services that include diagnostics (attended and HST), sleep therapy or sleep therapy supplies. For a complete list of authorization codes, please see the Provider Manual.

Getting prior authorization from CareCentrix 

There are three ways to obtain prior authorization from CareCentrix :

1. Online at https://www.sleepsms.com/ProviderPortal/homePage.do
2. By phone at 1-866-827-2469
3. By fax at 1-866-536-3618

The ordering provider is responsible for obtaining the required authorization number prior to performing any requested sleep service. Upon review of the sleep services request—and after all required clinical documentation has been received—CareCentrix will make medical necessity and site-of-service determinations within two business days for standard requests and three hours for urgent requests.

Failure to notify CareCentrix in advance of delivering a sleep study will result in administrative service and claims payment denials.

Receiving authorization or denial

Approvals will contain an CareCentrix authorization number and a CPT code specific to the requested procedure. Please note that the CareCentrix authorization number must be submitted with the claim in order to be paid by CareCentrix as the delegated network manager to include claims delegation. Claims for services that require prior authorization that are lacking an authorization number will be denied.

Claims payment process

1. Prior authorization number must be included on the claim.
2. The CPT codes billed must match the authorized CPT codes.
3. Claims should be submitted electronically. For more information, see the Carecentrix Provider Manual which can be found at www.carecentrixportal.com.
4. Claim status can be checked at www.carecentrixportal.com.

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

If you have any questions, please contact the Fallon Provider Relations Department at 1-866-275-3247, option 4, Monday through Friday from 8:30 a.m. to 5:00 p.m.

Updated August 18, 2023