Harvard Pilgrim's Sleep Studies Authorization Program

Harvard Pilgrim's Sleep Studies Authorization program is managed through an arrangement with National Imaging Associates (NIA). Harvard Pilgrim retains oversight of, and overall accountability for, all activities delegated to NIA.

Prior Authorization Required

Prior authorization from National Imaging Associates is required for home and attended sleep studies (polysomnography), split night studies and PAP titration for members 18 years of age and older.

National Imaging Associates

Harvard Pilgrim contracted with National Imaging Associates to provide utilization management of sleep diagnostic services for members 18 years of age and older enrolled in commercial HMO, POS, and PPO products. This program is designed to improve the quality of care being delivered to patients with sleep-disordered breathing, and optimally manage the utilization of these services while ensuring member access to appropriate, medically necessary care. Utilizing evidence-based guidelines consistent with American Academy of Sleep Medicine recommendations, NIA reviews all requests for sleep studies.

• NIA's guidelines can be found on its website www.radmd.com and are presented in a PDF file format that can be printed for future reference.

Utilization Review

Action Required–Ordering Provider

The ordering clinician is responsible for contacting NIA to request authorization prior to ordering sleep studies for Harvard Pilgrim members who are 18 years of age and older.

Authorization from NIA can be requested

• on-line at www.radmd.com or
• by telephone at 800-642-7543 (NIA's Call Center hours of operation are Mon.–Fri., 8 a.m.–8 p.m.).

Ordering providers should refer to NIA's website www.radmd.com/signup, for RadMD registration instructions.

Clinical indications and medical necessity of the planned procedure will be evaluated against NIA's evidence-based guideline algorithms. When NIA's medical necessity criteria are not met, a board-certified NIA physician will contact the ordering provider for a peer-to-peer conversation to obtain additional information and discuss potential treatment alternatives.

Authorization is not complete until consultation (if required) has been concluded and an approved authorization transaction number has been issued.

Failure to complete the authorization process will result in an administrative denial of the claim payment.

No authorization is required for members under 18 years of age. The servicing provider should submit claims for members under 18 years of age as per standard claims submission protocol.

Information Required

Referring physicians must provide the following information:

• Ordering physician name, Harvard Pilgrim provider number, and mailing address
• Member name, date of birth, and Harvard Pilgrim ID number
• Requested service/procedure descriptor or CPT code
• Diagnosis and/or ICD code
• All clinical information related to the request

NIA Response

When the authorization process is completed, a transaction number will be given to the caller, and a confirmation fax will be sent to the ordering clinician. NIA will also send written confirmation of approval and denial decisions to the member.

Harvard Pilgrim Health Care—StrideSM Medicare Advantage Provider Manual

October 2017

STRIDEsm (HMO) MEDICARE ADVANTAGE Sleep Studies Authorization (cont.)

If the request is approved, confirmation will also be faxed to the servicing provider. The approval will contain the following information:

• Approved transaction number

NIV12345)

• Planned procedure
• Servicing provider
• Date of service, if known

Denial letters will contain information needed to assist the member in understanding the reason(s) for the denial, and deciding whether or not to appeal the decision, including:

• The specific reason(s) for the denial, including clinical justification of the decision (consistent with generally accepted standards of medical practice); discussion of the individual member’s presenting symptoms or condition, diagnosis, and treatment interventions; and specific information upon which the adverse determination was based.
• The reason(s) that criteria were not met, including a reference to the benefit provision, guideline, protocol, or other criterion on which the denial was based, and notification that the member can obtain a copy of the actual information on which the denial was based.
• Any alternative treatment options offered by Harvard Pilgrim.
• The date that written or electronic confirmation was sent.
• Instructions as to how the member and/or physician can obtain a copy of the criteria used to make the determination.
• A description of appeal rights, including the right to submit written comments, documents, or other information relevant to the appeal; and an explanation of the appeal process including the right to member representation and timeframes for deciding appeals.

Action Required—Servicing Provider

Servicing providers are responsible for confirming that the ordering clinician has completed the prior notification/authorization process (before providing services) by requiring evidence of an approved NIA transaction number.

• Procedures should be scheduled only when an approved NIA transaction number is verified.
• If a patient calls to schedule an appointment for a procedure that requires authorization, and does not have the approved NIA transaction number, the patient should be directed back to the ordering clinician.
• If a provider/facility performs a procedure for which authorization was required but not obtained, the procedure will not be reimbursed, and the member cannot be balance billed

Status Inquiry

Electronic

Servicing providers can use electronic channels to determine if authorization has been completed. Authorization status and approved transaction numbers will be available to servicing providers through HPHConnect and NEHEN, usually within three hours of a completed notification process. Alternatively, status and transaction numbers can be accessed through NIA’s website, www.radmd.com.

• Detailed HPHConnect instructions are available at www.harvardpilgrim.org/providers. (Refer to the user guides at Harvard Pilgrim Health Care — Provider Manual May 2017 HPHConnect/User Guides. )
• For NEHEN instructions, refer to your NEHEN documentation.
• Refer to NIA’s website, www.radmd.com, for RadMD registration information

Phone Option

Providers may check the status of authorization requests by phone, 24 hours a day, 365 days a year, at 800-642-7543— select option 2 from the main menu. This service is specifically for status inquiries only.

Authorization Changes

NIA must be notified by telephone if any change to the original authorization occurs, such as a change to the procedure, a change to the servicing provider or a change to the date of service (if the new date of service exceeds the original date validity period). Records in HPHConnect, NEHEN and RadMD cannot be edited.

Harvard Pilgrim Health Care—StrideSM Medicare Advantage Provider Manual (continued)

October 2017

STRIDEsm (HMO) MEDICARE ADVANTAGE Sleep Studies Authorization (cont. )

Claims and