Home sleep testing for obstructive sleep apnea
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Temporary policy allowing medically necessary home sleep tests in lieu of facility-based sleep tests for Medi-Cal members during the COVID-19 pandemic; applies to physicians, participating physician groups, hospitals, and ancillary providers (with county limitations for Medi-Cal).
Effective immediately as a temporary added benefit, Health Net is permitting medically necessary home sleep tests in lieu of facility-based sleep tests for Medi-Cal fee-for-service members.
Facility-based sleep tests require prior authorization as indicated; home sleep tests also require submission of a prior authorization request with required medical records.
Coverage Criteria for Sleep Testing
Home Sleep Test (temporary pandemic benefit)
Covered when ALL of the following are met
Effective immediately as a temporary added benefit; continuation will be re-evaluated post-pandemic
Submit prior authorization request immediately using the Health Net Provider Portal; required medical records must be attached
Facility-based Sleep Test
Covered when ALL of the following are met
Facility-based testing remains subject to prior authorization starting December 15, 2020
This temporary allowance applies to Medi‑Cal fee‑for‑service members. Facility‑based testing may be limited or deferred during the COVID‑19 pandemic, and continuation of the extended benefit for home sleep testing will be re‑evaluated once the pandemic ends.
Coding
| No codes listed |
Provider Actions and Requirements
Prior authorization required for home and facility sleep tests
Prior authorization is required for home sleep tests immediately and for facility-based sleep tests for dates of service starting December 15, 2020. Submit the prior authorization request for each test along with the required medical records.
- Home sleep test: submit prior authorization request immediately with required medical records.
- Facility-based sleep test: submit prior authorization request with required medical records for dates of service starting December 15, 2020.
Provider actions — use portal and include records
Providers must submit prior authorization requests through Health Net and include required medical records; use the Health Net Provider Portal to view which services require prior authorization.
- Log in to the Health Net Provider Portal and select Transactions > Authorizations > Services Requiring Prior Authorization to confirm requirements.
- Include the required medical records with the authorization submission.
Prior authorization and documentation required
Submit a prior authorization request for a home sleep test immediately with the required medical records; for facility-based sleep tests, submit a prior authorization request with required medical records for dates of service starting December 15, 2020.
- Home sleep test: submit immediately with required medical records.
- Facility-based sleep test: submit for services starting 12/15/2020 with required medical records.
Denial risk if prior authorization or records are missing
Failure to submit a prior authorization request with the required medical records may result in denial of coverage for home sleep tests; facility-based sleep tests require prior authorization beginning December 15, 2020.
- Omitting required medical records with the authorization request risks denial.
- Do not assume facility-based testing is covered without prior authorization on/after 12/15/2020.
Background
Members with risk factors for obstructive sleep apnea (OSA) may be at increased clinical risk if untreated. During the COVID‑19 pandemic, conducting a home sleep test is permitted to keep patients safe at home and to obtain critical diagnostic information for these high‑risk patients. The temporary benefit for home testing will be re‑evaluated after the pandemic.
Definitions
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