Carelon Medical Benefits Management recognizes the key role that you and other providers play in the delivery of care for patients needing sleep testing and therapy services.

Developed in collaboration with your patients’ health plans, our Sleep Program supports providers in helping ensure patients receive sleep management services that are appropriate, safe, and affordable. The program leverages clinical appropriateness review (prior authorization) for certain sleep management services to promote a high standard of care through the consistent use of evidence-based criteria.

Our process

Carelon is here to assist in your efforts to deliver the best quality and affordable care for your patients. The clinical information you submit is reviewed against Carelon clinical guidelines and health plan specific guidelines to ensure alignment with current best practices. Therapy providers and physicians benefit by having a central location to obtain authorizations required by your patients’ health plans. This decision can be made immediately if all relevant clinical information is provided.

Carelon and your health plan are committed to a comprehensive solution for sleep disorder management designed to:

• Improve the clinical appropriateness of sleep testing and therapy services
• Help members find the highest value place of service for testing and therapy
• Monitor and manage patient compliance with sleep therapy

Contact Carelon to obtain pre-service review for the following sleep therapy testing and treatment services performed in a physician’s office, outpatient hospital department, or a free standing facility:

• Home Sleep Test (HST)
• In-Lab Sleep Study
  • Polysomnography (PSG)
  • Multiple Sleep Latency Testing (MSLT)
  • Maintenance of Wakefulness Testing (MWT)
• Titration Study
• Oral Appliances
• Initial Treatment Orders and Supplies (APAP, CPAP, BPAP)
• On-Going Treatment Orders and Supplies (APAP, CPAP, BPAP)
• Hypoglossal Nerve Stimulator

Note: Review requirements and modalities may vary by health plan. Please verify or check with the patient’s health plan if you have any questions.