Our Sleep Medicine program is an extension to our existing Utilization Management (UM) program. The Program is designed to manage testing and therapy services for sleep disorders and is administered by AIM Specialty HealthSM (AIM). Services managed under this program include:
- Titration studies
- Home sleep testing (HST)
- Oral appliances for sleep therapy
- In-lab sleep studies (Polysomnography [PSG])
- Initial treatment order (Automatic Positive Airway Pressure [APAP], Continuous Positive Airway Pressure [CPAP], Bilevel Positive Airway Pressure [BiPAP])
- Ongoing treatment order (APAP, CPAP, BiPAP)
Physicians and other health care professionals ordering services listed above must first contact AIM to request an order number prior to services being rendered. View the codes that require an order number on our Commercial Pre-authorization List or Medicare Pre-authorization List.
This applies to procedures performed in the following settings:
- Free-standing sleep center
- Outpatient hospital setting
- Outpatient basis in a physician office
Providers should contact AIM to obtain an order number before scheduling or performing any elective outpatient home-based (unattended) diagnostic study or a facility-based diagnostic or titration study (free-standing or hospital), as well as for sleep treatment equipment and related supplies. Authorization for ongoing sleep therapy will be dependent on member compliance data provided to AIM by the Durable Medical Equipment (DME) vendor. Please note:
- Supplies for APAP, CPAP, BiPAP do not require pre-authorization
- Compliance information for APAP, CPAP, BiPAP must only be submitted during the rent to purchase time period. Once the equipment has been purchased, we do not require compliance information.
Services performed in conjunction with any of the following are excluded from the program:
- Urgent-care facilities
- Inpatient hospitalization
- Emergency room services
- The program applies to new and existing sleep therapy patients.
- Ordering physicians (those referring the member for sleep testing) and servicing providers (those free-standing or hospital laboratories that perform sleep testing) may submit order requests.
- If it is determined by AIM that the service does not meet medical necessity criteria, the requested procedure will be denied and an order number will not be provided.
- If a sleep medicine provider performs the service without an approved order number, the procedure will be considered a provider write-off and cannot be billed to the member.
Members included in the program
This program applies to the following members residing in Idaho, Oregon, Utah and Washington as indicated below:
- Medicare Advantage Plans
- Group and Individual products
- KingCare℠ Health Plan (Group #10017241)
- Cambia Health Solutions (Group #60018408)
- Some Administrative Services Only (ASO) groups (PDF) (see below for more information)
Members excluded from the program
This program currently excludes:
- Federal Employee Plan
- Some ASO groups (PDF)
- Regence Bridge Medigap
- Alsco Inc. (Group #70000002), CHG Healthcare Services (Group #70000004), Dominion Questar (Group # 70000001), IEC Group (Group #70000000), U.A. Local Union 290 (Group #70000003)
- Regence Group Administrators (RGA)
- Any member where we are in the secondary coverage position
- Group, Individual and Medicare Advantage members receiving care outside of our service area
- BlueCard (Blue Cross Blue Shield members from other Plans who are not Regence members)
Administrative Services Only (ASO) groups
An ASO group may decide to purchase this benefit during their annual renewal period. The renewal period can vary by month, depending upon the group. It is therefore important to check on a monthly basis to determine if our ASO group list (PDF) has changed due to an ASO group purchasing the program.
Submitting requests for sleep testing and therapy services
Both ordering physicians (those referring the member for sleep testing and therapy) and servicing providers (those who provide the sleep testing and therapy) may submit requests for sleep testing and therapy on behalf of members. Please note: Durable Medical Equipment (DME) suppliers may only submit requests for sleep therapy services.
Contact AIM online via AIM's ProviderPortal or call toll-free at 1 (877) 291-0509, Monday through Friday 8 a.m. - 5 p.m. PST to submit your request for an order number. The preferred way to submit a request is online as a provider's office can often get an immediate approval.
Completing the OptiNet Assessment
Facilities, sleep laboratories, and DME providers must complete an online assessment on OptiNet®.
OptiNet is an online provider registration tool that collects information on the facility, such as services, staffing and accreditation. Facility, sleep laboratory and DME provider data provided will become an important part of the information available to ordering physicians and members.
To be included in AIM's OptiNet directory, you must complete the online assessment. If you have not previously registered with AIM, you will first need to do so. The registration tool is available through the ProviderPortal.
OptiNet allows you to complete the registration at your convenience; it can be initiated, paused and saved as necessary. Select Regence from the drop-down menu, and proceed with the assessment.
Please note: You do not need to complete the survey if you only read sleep testing results and do not perform the technical and/or global component of these services.
The information gathered from the OptiNet registration will:
- Be made available to ordering physicians during the sleep management request process and used to educate users in the Provider Selection component of the order request process.
- Allow ordering physicians to choose a servicing provider from the online directory based on their ability to provide home sleep testing, facility-based sleep testing and DME services.
How to register with AIM to order sleep studies or DME services
Providers currently using AIM's website for radiology authorizations DO NOT need to re-register. All other providers who will require access to the AIM website to obtain authorization or check on authorization status must register. For large group practices, AIM can offer assistance with the registration process. Contact AIM at 1 (877) 291-0509.