Prior Authorization for Site of Service Attended Polysomnography for Evaluation of OSA
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This document governs prior authorization requests and required form information for site-of-service attended polysomnography (sleep study) for evaluation of OSA for HealthPartners members. It affects ordering clinicians, facilities, and sleep specialists submitting authorization requests.
No material clinical or coverage changes in this revision.
Form-based Coverage Submission Requirements
Form-based coverage submission requirements
Authorization form captures diagnosis codes, procedure codes, and urgency; clinical justification and diagnoses are required to support the request.
ALL of the following
- Primary diagnosis code (required)
- Secondary diagnosis code (optional)
Polysomnography CPT Codes
Submission, Contact, and Provider/Facility Requirements
Submission and contact information for prior authorization
Fax completed forms to (952) 853-8712. Call Utilization Management (UM) at (952) 883-6333 with questions. Incomplete forms will be returned. Authorizations and referrals link to check the status of your prior authorization request.
- Fax for completed forms: (952) 853-8712
- UM phone for questions: (952) 883-6333
- Note: Incomplete forms will be returned
- Use authorizations and referrals link to check prior authorization status
Urgent review question
Will waiting the standard review time seriously jeopardize the member's health, life, or ability to regain maximum functioning? The form requires answering Yes or No and providing a clinical reason for urgency (scheduling issues are not acceptable grounds).
- Question requires Yes/No selection
- If Yes, provide clinical reason for urgency (not scheduling issues)
Required provider and facility information
Provide complete ordering provider and facility details on the request form. Missing or incorrect information (for example NPI or tax ID) can cause claim rejection or delays. Confidential voicemail is required for listed phone numbers; provide a fax for outcome notification where indicated.
- Ordering physician: first name, last name, specialty, NPI, clinic name, street address, city, state, zip, clinic tax ID (claim may be rejected if incorrect), email, phone, fax
- Sleep specialist (if applicable): checkbox if same as ordering physician; otherwise provide first/last name, specialty, NPI, clinic name, address, city, state, zip, clinic tax ID (claim may be rejected if incorrect), email, phone, fax
- Facility/site: facility name, street address, city, state, zip, billing tax ID (claim may be rejected if incorrect), phone (confidential voicemail required)
- Reference: HealthPartners form identifier 20-913603-913616
Site of Service Attended Polysomnography
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