CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Authorization Request Form for Sleep-Related CPT Codes

This document is an authorization request form used by Blue Cross Blue Shield - Tennessee to collect clinical and provider information for precertification of selected sleep-related CPT codes for members age 18 and older. It affects Tennessee providers (and notes submission options for out-of-state providers).

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyAuthorization Request Form for Sleep-Related CPT Codes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit authorization requests via Availity for Tennessee providers and include selected CPT codes plus supporting clinical information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6CPT codes listed that require precertification

18+Age threshold for precertification requirement

1phone number for prior authorization questions

AvailityTennessee provider submission portal

Requested Clinical Information

Information requested to support authorization (providers should check applicable items and attach clinical documentation):

ALL of the following

Contact Name
Date of Service
Phone
Fax

ALL of the following

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyAuthorization Request Form for Sleep-Related CPT Codes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit authorization requests via Availity for Tennessee providers and include selected CPT codes plus supporting clinical information.

SourceLink

On This Page

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Sleep Study CPT Codes and Eligibility

Sleep study CPT codes requiring precertificationCPT

95807	CPT code listed for precertification (provider-selected)
95808	CPT code listed for precertification (provider-selected)
95810	CPT code listed for precertification (provider-selected)
95811	CPT code listed for precertification (provider-selected)
95805	CPT code listed for precertification (provider-selected)

Precertification requirement age threshold (context)mixed

18+	Precertification required for individuals 18 and older

Age threshold

Age thresholdPrecertification required for individuals 18 and older

Applicable CPT codesPrecertification applies to listed sleep study CPT codes (see form) for members aged 18+

ScopeApplies to authorization/precertification requests submitted for members 18 years and older

Prior Authorization Requirements and Submission

Prior Authorization

Prior Authorization Required

Precertification is required for the listed sleep study CPT codes for individuals age 18 and older. Complete the clinical information section and attach pertinent clinical documentation when submitting the request.

CPT codes requiring precertification: 95807, 95808, 95810, 95811, 95805
Clinical elements to include: Epworth Sleepiness Scale score (if >10), BMI (if >30), reports of snoring, excessive daytime sleepiness, observed apnea or choking episodes, comorbidities, diagnosis with diagnosis code(s), contact name, date of service, phone, fax

Note

Submission and Contact Instructions

Complete the provider information and submission form and attach all pertinent clinical information. Tennessee providers: submit authorization requests at any time via Availity. Out-of-state providers: submit authorization requests through your provider portal or Cohere. For prior authorization questions, call (423) 535-5717, option 2, or contact your eBusiness Network Manager.

Submission options: Availity (Tennessee providers), provider portal or Cohere (out-of-state providers)
For questions about submitting a prior authorization request: call (423) 535-5717, option 2
Include completed provider information: place of service, physician and facility details, NPI, tax ID, phone and fax

Authorization Request Form Fields

Authorization Request (precertification form) — required fields

Member identifiersMember name, date of birth, Member ID (include prefix), reference number

Provider & contact detailsContact name, phone, fax, date of service

Clinical data requestedComorbidities, diagnosis with diagnosis code(s), Epworth Sleepiness Scale score, BMI, symptoms (snoring, excessive daytime sleepiness, observed apnea or choking)

CPT code selectionForm requires provider to select applicable CPT codes (95807, 95808, 95810, 95811, 95805)

Supporting documentationPlease attach pertinent clinical information to support the request